context week 6 Flashcards
why are the terms “buckle fracture” and “greenstick fracture” associated with children #
children’s bones tend to buckle/partially fracture/splinter with some degree of continuity of some “fibres” of bone (like breaking a green stick from a tree) rather than break completely.
why do childrens # heal quicker than adults?
thicker periosteum which is a rich source of osteoblasts.
what does the periosteum do?
serves to increase the width/circumference of growing long bones
what are the differences in periosteum in children and adults
in kids is much thicker and tends to remain intact which can help stability and can assist reduction if required.
what do children bones have a greater potential for?
remodelling
why do childrens bone have a greater remodelling potential
because they grow with bone being formed along the line of stress and children can correct angulation up to 10° per year of growth remaining in that bone.
are kids # treatment in comparison to adults
less likely to need surgery with greater degrees of displacement or angulation can be accepted.
If the fracture position is unaccepatable, manipulation and casting may be all that is required accepting a degree of residual angulation or displacement.
when are childs # treated like adults
puberty [12-14]
around where has the potential to disturb growth
physis (growth plate)
what happens if physis is disturbed by #
shortened limb or an angular deformity if one side of the physis is affected by growth arrest.
what classification is used for paediatric physeal #’s?
Salter-Harris classification of physeal fractures
what is salter-harris I #
pure physeal separation.
best prognosis and is least likely to result in growth arrest.
what is salter-harris 2 #
similar to 1 but has a small metaphyseal fragment attached to the physis and epiphysis.
growth disturbance risk is low.
commonest physeal #.
Salter‐Harris III and IV #’s
’s reduced and stabilized to ensure a congruent articular surface and minimize growth disturbance.
intra‐articular and with the fracture splitting the physis
greater potential for growth arrest
Salter‐Harris V injury
compression injury to the physis with subsequent growth arrest.
cannot be diagnosed on initial x‐rays; only detected once angular deformity has occurred.
Non accidental injury (NAI) risk factors
poverty,
children with special needs or disability.
parents who are substance abusers.
what raises concern of child abuse/NAI
Multiple fractures of varying ages (with varying amounts of callus or healing)
multiple trips to A&E with different injuries
other features that raise suspicion of NAI
Inconsistent / changing history of events
Discrepancy of history between parents / carers
History not consistent with injury
Injuries not consistent with age of child eg non walking child
Multiple bruises of varying ages
Atypical injuries eg cigarette burns, genital injuries, torn frenulum, dental injuries, lower limb
and trunk burns
Rib fractures
Metaphyseal fractures in infants
what should occur in NAI suspected case
paediatrics involved ASAP and admitted for saftey.
Full exam and history taking performed
examples of common paediatric fractures
distal radius, forearm, supracondylar of elbow, femoral shaft, tibial #’s
what are some examples of paediatric distal radius #’s
buckle, greenstick, salter-harris II
Buckle fractures (how stable? treatment?)
stable
require only 3‐4 weeks of splintage.
Greenstick fractures (describe variation + treatment)
may be angulated
may require manipulation + casting if significant deformity (particularly in the older child)
Salter‐Harris II fractures. (where, problems and treatment)
distal radial physis (occurs in older children)Angulation with deformity requires manipulation. Growth problems are highly unlikely (as with most Salter Harris II fractures).
Complete distal radius fractures
may displace as well as angulate with dorsal displacement and angulation more common than volar.
The dorsal periosteum usually remains intact which prevents overcorrection of the deformity and aids stability.
treatment of Complete distal radius fractures
If the fracture is fairly stable, casting may suffice.
If a complete fracture is very unstable after reduction, wire stabilization or plate fixation may be employed.
forearm #’s
Monteggia and Galeazzi fracture‐dislocations
treating forearm #’s in kids
These injuries go against the usual principles of children’s fractures, in that anatomic reduction and rigid fixation with plates and screws is typically used to treat these injuries. There is a high rate of re‐dislocation of the radial head or distal radio-ulnar joint (DRUJ) if only manipulation and casting is used.
fractures of both bones of the forearm (types and treatment)
angulated fractures → have an intact periosteum and the instability may only be in one plane → controlled with a cast after manipulation.
Displaced fractures → unstable and flexible → intramedullary nail
what are Supracondylar fractures of the elbow common
relatively weak point in the growing upper limb
two types of Supracondylar fractures
extension - more common and occur due to a heavy fall onto the outstretched hand
flexion - a fall onto the point of the flexed elbow.
treatment of supracondylar #’s
Undisplaced fractures → stable → splint.
Angulated, rotated or displaced # → closed reduction and pinning with wires → prevent deformity
also severely displaced / off‐ended fractures (see later card)
severely displace/off-ended supracondylar # problems
brachialis muscle may be tethered in the fracture site
With off‐ended extension type fractures the distal fragment displaces posteriorly with stretch and pressure on the brachial artery and median nerve (predominantly its anterior interosseous branch – the patient is unable to make the “OK” sign due to loss of FPL and FDP to the index).
supracondylar Displaced fractures treatment
reduced fairly soon to avoid swelling which can make reduction more difficult.
radial pulse is absent or reduced in volume then emergency surgery ASAP [Closed reduction may be performed with wiring and the pulse may return if the artery is no longer under stretch. if hand remains pulseless after reduction, open surgical exploration is required.]
nerve injury then surgery urgently. majority are neurapraxias and occasionally axonotmesis [normally improve]. neuralgic pain or no improvement may indicate entrapment of the nerve. do surgical release
why do Femoral shaft fractures occur?
children due to a fall onto a flexed knee or by indirect bending or rotational forces.
what can occur in femoral shaft fracture healing process in kids
overgrowth tends to occur after fracture healing and therefore some shortening can be accepted (more with younger children).
femoral shaft # In children less than 2 years old [cause and treatment]
more than half of femoral shaft fractures are due to NAI .
Gallows traction and early hip spica cast
femur shaft # in children aged between 2 and 6 treatment
Thomas splint or a hip spica cast.
femur shaft # in children between 6 and 12 treatment
femur is large enough to accommodate flexible intramedullary nails which obviate the need for traction or cast.
children aged 12 and above femur shaft # treatment
adult type intramedullary nail is typically used.
what to remember to check in femur fractures
femur is a common site for benign and malignant bone tumors and the fracture may be pathological with osteolysis and cortical thinning
(also if young then NAI)
undisplayed tibial #’s occur in what age group and are treated with what
Undisplaced spiral fractures of the tibial shaft are common in toddler’s (the injury is known as a “toddler’s fracture”)
require a short time in cast.
treating tibial #s
mainly cast for majority.
compartment syndrome risk less than adult.
up to 10 degrees angulation allowed or manipulated
serial x-rays to check doesn’t drift into excessive angulation. shortening or malrotation also unaccepted
very unstable or open tibial #s
stabilise = flexible intramedullary nails, plates and screws or external fixation.
Adolescents with a closed proximal tibial physis give adult intramedullary nail.
C-spine #
high energy injuries (RTA, fall from height) + associated with head injury.
Potentially dangerous unstable fractures may be missed in the unconscious or confused patient which may result in spinal cord injury. therefore C‐spine immobilization with a hard collar and sand bags or blocks on a spinal board
how to clinically clear C-spine injury
No history of loss of consciousness
GCS 15 with no alcohol intoxication
No significant distracting injury (such as head injury, chest trauma or other fractures including more distal spinal fractures)
No neurological symptoms in the upper or lower limbs
No midline tenderness on palpation of the c-spine
No pain on gentle active neck movement (ask the patient to gently flexed forward, then rotate to each side)
what to do if c-spine cannot be clinically cleared
collar must stay in situ.
Further imaging in the form of X‐Rays (AP & lateral views +/‐ odontoid peg open mouth view) or CT scan of the c‐spine is required so that a c-spine injury can be radologically cleared
what to do in any suspected c-spine injury
full trauma assessment (ABCD) and a full neurological examination including:
peripheral motor function coarse touch sensation upper & lower limb reflexes cranial nerve evaluation rectal examination, and assessment of bulbocavernous reflex.
what height are c-spine dislocations/’s especially fatal
c3 or above (as phrenic nerve suppling diaphragm is C3,4,5.)
treatment of stable c-spine injuries
firm cervical collar
treatment of unstable injuries of c-spine
immbolise in “halo vest” (external fixation)
surigcal stabilisation with fusion/wiring/internal fixation
c-spine Subluxations and dislocations treament
traction for reduction and halo application or operative stabilization
burst fracture with neurological deficits treatment
traction to decompress spinal cord
why do thoracolumbar spine fractures occur
- motor vehicle accidents or falls from a height. give burst fractures or chance fracture-dislocation
- elderly with osteoporosis osteoporotic “wedge” insufficiency fractures ( do not require anything other than symptomatic treatment.)
what does any thoracolumbar injury require?
full trauma evaluation and neurological assessment
treatment of thoracolumbar injury
stable of throacic spine= brace to limit flexion/kyphosis
stable lumbar spine = plaster jacket for presrve lordosis.
examination of thoracolumbar spinal fractures
posterior bony or ligamentous involvement detected by local tenderness, swelling and palpable defect on exam
indication for surgery of thoracolumbar #
Presence of neurological deficit (especially if progressive or very unstable injury)
Unstable injury pattern with substantial loss of vertebral height, displacement or involvement of the posterior ligamentous structures.
what might surgery of thoracolumbar # involve
Surgery may involve stabilization with pedicle screws and rods, spinal fusion and decompression.
what can cause spinal cord injuries?
contusion, compression, stretch or laceration.
what does vascular disruption and oedema cause in spinal cord injuries?
further ischaemic damage and hypotension, hypoxia and inflammatory responses may also result in secondary damage.
what is Spinal shock
physiologic response to injury with complete loss of sensation and motor function and loss of reflexes below the level of the injury. Spinal shock usually resolves in 24 hours with return of reflexes and the severity of a spinal cord injury may not be determined until after spinal shock has resolved
what reflexes can be asessed in spinal shock?
The bulbocavernous reflex
contraction of the anal sphincter with either a squeeze of the glans penis, tapping the mons pubis or pulling on a urethral catheter. The bulbocavernous reflex is absent in spinal shock and its return signals the end of spinal shock.
what is Neurogenic shock
occurs secondary to temporary shutdown of sympathetic outflow from the cord from T1 to L2, usually due to injury in the cervical or upper thoracic cord leading to hypotension and bradycardia which usually resolves within 24‐48 hours.
what can occur in neurogenic shock
Priapism (prolonged erection), due to unopposed parasympathetic stimulation
treating neurogenic shock
Neurogenic shock is treated with IV fluid therapy.
Neurogenic shock must be differentiated from other forms of shock (e.g.: hypovolemic shock also responds to fluid replacement )
two classifications of spinal cord injury
complete or incomplete
Complete spinal cord injury
- results in no sensory or voluntary motor function below the level of the injury (reflexes should return).
- The level of the injury is determined by the most distal spinal level with partial function (after spinal shock has resolved) as determined by the presence of dermatomal sensation and myotomal skeletal muscle voluntary contraction.
- The prognosis for recovery from complete cord injuries is poor.
incomplete spinal cord injuries,
- some neurologic function (sensory and/or motor) is present distal to the level of injury.
- In general, the greater the function present, the faster the recovery is and the better the prognosis.
- Sacral sparing with preservation of perianal sensation, voluntary anal sphincter contraction and big toe flexion (FHL muscle, S1/2) indicates some continuity of the corticospinal (motor) and spinothalamic (course touch, pain, temperature) tracts. The presence of sacral sparing indicates an incomplete cord injury with a better prognosis than a complete injury.
treatment of spinal cord injury
Full ATLS primary survey with resuscitation and protection of the cervical and thoracolumbar spine is mandatory.
appropriate immobilisation, traction, surgery, ventilation support, multi-disiplanry approach
name the 4 types of incomplete spinal cord injuries
central, anterior, posterior cord syndromes and brown-swquard syndromes
Central cord syndrome signs
commoonest, hyperextension injury in C-spine with OA.
often no associated fracture or dislocation. paralysis or arms more than legs. (as central in cord is upper motor neurones mainly) sacral sparing typical .
anterior cord syndrome signs
loss of motor function, coarse touch, pain, temp sensation below injury height.
proprioception, vibration sense and light touch preserved
posterior cord syndrome signs
loss of dorsal column function is rare (vibration sense, proprioception, light touch)
Brown‐Sequard syndrome signs
results from hemisection of the cord usually from penetrating injury eg stab wound. Ipsilateral paralysis and loss of dorsal column sensation occurs with contralateral loss of pain, temperature and coarse touch sensation. This is due to nerve fibres of the spinothalamic tracts crossing to the other side of the cord one or two levels above their entry into the cord whilst the nerve fibres of the other tracts cross higher up in the medulla
pelvic #
young=high energy
old= low energy possible due to osteoporosis
if pelvic ring disputed then always > 1 place (polo mint)
what forms the pelvic ring?
sacrum, ilium, ischium and pubic bones with strong supporting ligaments.
pelvis # complications
Branches of the internal iliac arterial system and the pre‐sacral venous plexus are prone to injury with risk of serious hypovolaemia.
Nerve roots and branches of the lumbo‐sacral plexus are prone to injury.
what are the three main patterns of injury in pelvis?
lateral compression #, vertical shear #, anteroposterior compression injury
lateral compression fracture
occurs with a side impact (eg RTA) where one half of the pelvis (hemipelvis) is displaced medially. Fractures through the pubic rami or ischium are accompanied by a sacral compression fracture or SI joint disruption.
vertical shear fracture
occurs due to axial force on one hemipelvis (eg fall from height, rapid deceleration) where the affected hemipelvis is displaced superiorly. The sacral nerve roots and lumbosacral plexus are at high risk of injury and major haemorrhage may occur. The leg on the affected side will appear shorter.
anteroposterior compression injury
may result in wide disruption of the pubic symphysis the pelvis opening up like the pages of a book – the so‐called open book pelvic fracture. Substantial bleeding from torn vessels occurs and as the pelvic volume increases exponentially with the degree of displacement, with widely displaced injuries the pelvis can contain several litres of blood (ie the entire circulating volume) before tamponade and clotting will occur.
high-energy pelvic # treatment
associated with other injuries
blood loss treat
with open book pelvic # promptly reduce the displacement and minimise pelvic volume to allow tamponade of bleeding to occur. Application of a tied sheet or a special pelvic binder around the outside of the pelvis will hold the reduction temporarily and allow clotting of the vessels. An external fixator will provide more secure initial stabilization.
Ongoing haemodynamic instability despite these measures may require angiogram and embolization or open packing of the pelvis if laparotomy is required for co‐existing intra‐abdominal injuries.
Bladder and urethral injuries (blood at the urethral meatus) may also occur and urinary catheterization may risk further injury. Urological assessment and intervention may be required. A PR exam is mandatory to assess sacral nerve root function and to look for the presence of blood. The presence of blood indicates a rectal tear rendering the injury an open fracture and carries a higher risk of mortality. General surgical review is mandatory and defunctioning colostomy may be required.
treating low energy pelvic #’s
Low energy pubic rami fractures in the elderly tend to be minimally displaced lateral compression injuries (with sacral fracture or SI joint disruption posteriorly) and settle with conservative management over time.
acetabulum #’s
Acetabular fractures are usually high energy injuries in the younger patient but can be low energy in the older patient.
Posterior wall fractures may be associated with a hip dislocation. In these cases, the posterior wall is fractured as the head of the femur is pushed out the back of the joint. (RTA)
The pattern of the fracture can be difficult to determine on plain X‐rays (oblique views may help) and CT scans help to determine the pattern of the fracture and are essential for surgical planning.
treatment of acetabulum #’a
Undisplaced fractures or small wall fractures may be treated conservatively. As with most intra‐ articular fractures, unstable or displaced fractures require anatomic reduction and rigid fixation in the younger patient to reduce the risk of post traumatic OA. Older patients may be treated with total hip replacement – either early (with an uncemented cup and screws) or delayed.
examples of shoulder trauma
humeral neck #, shoulder (gleno-humeral) dislocations, ACJ (Acromioclavicular joint) injuries
humeral neck #’s common cause
Proximal humerus fractures are common with the majority being low energy injuries in osteoprotic bone due to a fall onto the outstretched hand or directly onto the shoulder.
humeral neck # pattern of #
The most common pattern is a fracture of the surgical neck (rather than the anatomic neck) with medial displacement of the humeral shaft due to pull of the pectoralis major muscle. The greater and lesser tuberosities may also be avulsed with the attachments of Supraspinatus, Infraspinatus and teres minor for the greater tuberosity and subscapularis for the lesser tuberosity. Isolated fractures of the greater tuberosity and head‐splitting intra‐articular fractures can also occur.
treatment of humeral neck #
Many minimally displaced proximal humerus fractures are treated conservatively with a sling and gradual return to mobilization
displaced= the position often improves once muscle spasm settles.
permanametly displaced = internal fixation (plate, screws, wires or intramedullary nail) but stiffness, chronic pain and failure of fixation can occur particularly in the older patient.
consequences of humeral head #
pain and/or loss of motion. AVN of humeral head causing chronic pain. bone fragments may need cut out or fixed as leads to failure, shoulder replacement can be used. (Head splitting fractures usually require shoulder replacement unless the patient is younger with very good bone quality.)
gleno-humeral dislocation which type is more common?
Anterior shoulder dislocation is much more common than posterior dislocation (the latter contributing only 2‐5% of all shoulder dislocations).
Traumatic anterior shoulder dislocation occurs due to what?
excessive external rotation force or a fall onto the back of the shoulder. also seizure (watch for bilateral dislocations)
what is the pathophysiology of a Anterior shoulder dislocation
often detachment of the anterior glenoid labrum and capsule known as a Bankart lesion whilst the posterior humeral head can impact on the anterior glenoid producing an impaction fracture of the posterior head (Hill‐Sachs lesion)
what can be compromised in Anterior shoulder dislocation
auxillary nerve can be stretched as it passed through quadrilateral space witle axially artery and other bracial plexus nerves can be affected.
finding on clinical assessment of anterior shoulder dislocation
Loss of symmetry is seen with loss of roundness of the shoulder and the arm held in an adducted position supported by the patients other arm. The principle sign of axillary nerve injury is loss of sensation in the regimental badge area. It may be difficult to determine deltoid contraction in the acute phase. Full distal neurovascular assessment should be carried out. In older patients, tears of the rotator cuff are very common but again these can be difficult to assess in the acute setting.
investigations of anterior shoulder dislocation
x-rays to confirm.
also surgical neck and greater tuberoity # can occur with shoulder dislocation
Management of ant shoulder dislocation
Closed reduction (under sedation or anaesthetic) is the mainstay of treatment with neurovascular assessment before and after reduction. Radiographs are repeated to confirm reduction. The patient is placed in a sling for 2‐3 weeks to allow the detached capsule to heal then rehabilitation with physiotherapy is commenced. Delayed presentation dislocations (eg alcoholics) may be difficult to reduce by closed means and may require open reduction..
associated fracture of the greater tuberosity, this usually reduces to an acceptable position with reduction of the shoulder however ORIF is usually required if it remains displaced. Fracture‐dislocations involving the surgical neck usually require surgery.
risk of shoulder redislocation
The risk of recurrent dislocation is predicted by the age of the patient at the time of initial dislocation.
Patients less than 20 have an 80% chance of re‐dislocation and many surgeons advocate stabilization surgery after first time dislocation in this age group. Patients over 30 have only a 20% risk of further dislocation and the re‐dislocation rate reduced further with increasing age. Recurrent dislocations can be stabilized by a Bankart repair with reattachment of the torn labrum and capsule by arthroscopic or open means.
Some shoulder dislocations occur in patients with marked ligamentous laxity (who and treatment)
EDS/marfan’s causes this. atraumatic multi-directional dislocation (which may be painful), open tightening gf shoulder capsule possible + physic to strengthen RC is treatment
causes of Posterior shoulder dislocations
posterior force on the adducted and internally rotated arm
investigating Posterior shoulder dislocations
The humeral head may be palpated posteriorly. They are often missed as the radiographic findings are much less obvious than anterior dislocation. The main Xray finding is the “light bulb” sign where the excessively internally rotated humeral head looks symmetrical like a light bulb on an AP view. Special lateral xray views assist in the diagnosis.
treatment of Posterior shoulder dislocations
Closed reduction and a period of immobilization followed by physiotherapy are again the mainstay of treatment.
why do ACJ injuries occur?
Injuries of the acromioclavicular joint usually occur after a fall onto the point of the shoulder. They are a fairly common sporting injury.
classification of ACJ injuries
sprained, subluxed (the acromioclavicular ligaments are ruptured) or dislocated. ( the coracoclavicular ligaments (conoid and trapezoid ligaments) are also disrupted )
treatment of ACJ injuries
Most injuries are treated with conservative management wearing a sling for a few weeks followed by physiotherapy.
surgery (reconstruction of the coracoclavicular ligaments) is reserved for those with chronic pain (although some surgeons advocate early reconstruction for younger athletes with dislocation – controversial).
what causes a humeral shaft #
direct rauama (RTA) results in transverse or comminuted #.
fall +/- twisting injury resulting in oblique or spiral #.
recovery from humeral shaft #
Union rates are high (90%) and due to the mobility of the ball and socket shoulder joint proximally and the elbow joint distally, up to 30° of angulation can be accepted.
complications of humeral shaft #
The radial nerve in the spiral groove is susceptible to injury which present with a wrist drop and loss of sensation in the first dorsal web space.
treatment of humeral shaft #
Most cases are treated non-operatively with a functional humeral brace which compresses the fragments into acceptable alignment and provides some stability.
Internal fixation with an intramedullary nail or plate and screws may afford a quicker recovery and intramedullary nailing may be used in polytrauma. Non unions require plating and bone grafting.
common elbow injuries
supracondylar # (paediartic )
intra-articular distal humerus #
olecranon #
radial head and neck #
elbow dislocation and fracture dislocation
Intra‐articular distal humerus fractures treatment
As with most intra‐articular fractures, these require open reduction, internal fixation (ORIF) with anatomic reduction and rigid fixation to minimize loss of function. Special plates are available to follow the complex contours of the distal humerus. Elbow replacement can be considered in highly comminuted fractures in the elderly.
Olecranon fracture
common, due to fall onto pint of elbow with contraction of tricep. mostly ORIF to restore tricep function and articular surface.
Olecranon fracture treatment
A simple transverse avulsion fracture can be fixed with tension band wiring which compresses the tension side of the fractures. Comminuted fractures don’t have a fulcrum for the tension band and require ORIF with a plate and screws.
Radial head & neck fractures due to what?
Radial head and neck fractures usually occur due to a fall onto the outstretched arm.
investigating radial head and neck #s
Some undisplaced fractures may not show up on x‐ray other than a fat pad sign on the lateral x‐ray (a triangle like a sail anterior to the distal humerus) with lateral elbow pain on supination / pronation.
treating Radial head & neck fractures
Undisplaced or minimally displaced fractures are treated conservatively with a sling for comfort followed by early elbow exercises to minimize stiffness. Patients often lose 10‐15° of terminal extension. Displaced intra‐articular radial head fractures may require surgery if the displaced fragment causes a mechanical block to full extension. Aspitation of the haemarthrosis and injection of local anaesthetic may help to exclude those with restricted ROM due to pain. ORIF is performed if the fragment is large enough or excision if not amenable to fixation.
elbow dislocation
Most elbow dislocations occur in the posterior direction after a fall onto the outstretched hand. They may be associated with neurovascular injury. Uncomplicated dislocations require closed reduction under sedation assessing neurovascular status pre‐ and post‐reduction. A short period in sling (1‐3 weeks) followed by elbow exercises is typically required.
In elbow fracture-dislocation, what are the common # that occur with elbow dislocation
Associated fractures of the radial head, humeral epicondyles or coronoid process of the ulna.
treating elbow fracture dislocation
Surgery may be required if entrapped bony fragments prevent reduction or block motion. Radial neck or head fractures may require ORIF or excision and replacement with a prosthetic radial head to maintain stability.
Epicondyle fractures are fixed with a screw. Large coronoid fractures may need ORIF with small screws to prevent recurrent dislocation. Some cases with recurrent instability may be helped with lateral elbow ligament reconstruction.
forearm # principles
forearm consists of radius nd ulna bone connected proximally and distally by strong ligaments around the respective radio-ulnar joints (where supination/pronation occurs).
because of strong ligaments forearm acts as a ring (so ifone bone #/dislocated then other is likely to be as well)
Fracture of ulnar shaft is know as?
nightstick #
